Podcast #171 - IPV Educators: Dogmalysis of the History and Physical in Pediatric Abuse/Neglect

Katherine (Katie) Thompson from IPV Educators is back to discuss some more pearls in regards to abuse and neglect.  This time, we talk about dogma regarding the history and physical exam components specifically for pediatric abuse and neglect.  We pay particular attention to the incorrect dogma that can impact our management.

We are starting a series of podcasts with IPV Educators to specifically discuss pediatric nuances.  For the first portion, we want to cover the dogma of the history and physical in pediatric abuse and neglect.  We have talked about dogma and more accurately dogmalysis in previous podcasts.  The two main podcasts we have covered on this have been regarding dry drowning andheat stroke.

Common domga that is wrong:

• Reporting a case is only to be used as a last ditch effort.
  • The agencies we are contacting are meant to help and they can provide a number or resources.
  • Many cases that we report may not result in a child being taken from their home but instead result in the family getting much needed help in a variety of forms.
  • Most agencies work on a "family first" basis meaning they want to keep the home intact (child and caregiver) whenever possible.
• By reporting, you ruin a relationship or rapport you have established.
  • Often, the family may anticipate us reporting and sometimes might request it (especially in the cases of a third party harming the child).
  • However, there are merits in certain situations to report and not tell the family. 
    • Times to consider not doing this is if there is concern that the family will try to hide evidence that could be beneficial for the agency to find.
    • This is a rather complex topic and discussed more in the podcast.
    • However, the family  might be very upset by not knowing especially in cases where there ends up being no evidence of wrongdoing.
  • Overall, like most of this discussion, remember this is situation dependent and should be taken on a case-by-case basis.
• Proof is necessary to report a possible case.
  • Physical evidence is not necessary to report a possible case.
  • Only the suspicion of abuse or neglect is needed to report a case and express our concerns.
• It is easy to ruin the case during the history and physical exam.
  • We will talk about this more in the next podcast.
  • A limited history and physical like we would do during our daily routine is unlikely to cause significant harm to a case or the surrounding evidence.
  • There are usually resources close at hand that can help guide you on what should or should not be done at the local level.
• Each situation is too unique to create any sort of guideline, plan, protocol, etc.
  • While each case is unique,  there are resources available  (such as this podcast and IPV Educators) that can help you walk through how to create something for your facility.
  • Local law enforcement and child welfare centers can further help especially when customizing this for the local level.
  • The more you have in place usually the more successful and streamlined the process will be.
• The questions asked to the child will either traumatize them or be inaccurate because of how it is asked.
  • It is important to understand how to ask basic open-ended questions and again this will be discussed more in the next podcast.
  • Ask the caregiver to help define certain terms in advance whenever possible (such as what the patient would call their penis, rectum, or vagina).
• Physical exam findings in abuse are clear cut and easy to find.
  • There are some classic findings for abuse (such as a mid-shaft femur fracture in non-mobile infants or certain vaginal lacerations).
  • The vast majority of cases of abuse will have little to no findings and many can be non-specific.
  • It will be the combination of the history and physical that will help provide the information needed to  make an informed decision about reporting.
• Alternative medicine and those practices are abusive to children.
  • Cultural differences are intricate and can be confusing for those not familiar.
  • The main point is to make sure that these alternative therapies or cultures are not causing harm to the child.
  • Cupping and coining are frequently used in certain cultures but usually do not cause any lasting effects and are not harmful to the patient.
  • Denied treatments that can be life-saving or of critical importance are very concerning and should be addressed appropriately.

Resources that Katie mentioned:

• Adams paper  on  Interpretation of Medical Findings in Suspected Child Sexual Abuse: An Update for 2018
• The Spirit Catches You and You Fall Down 

​Let us know what you think by giving us feedback here in the comments section or contacting us on Twitter or Facebook.  Remember to look us up on Libsyn and on iTunes.  If you have any questions you can also comment below, email at thetotalem@gmail.com, or send a message from the page.  We hope to talk to everyone again soon.  Until then, continue to provide total care everywhere.

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